Clinical Practice Guidelines on the Diagnosis and Treatment of Acute Calculus Cholecystitis (WSES, 2020)
Clinical practice guidelines on the diagnosis and treatment of acute calculus cholecystitis (ACC) were updated in November 2020 by the World Society of Emergency Surgery. [26] Highlights are below. For more information, go directly to the guidelines.
Diagnosis
The suggested combination for diagnosis is a detailed history, complete clinical examination, laboratory testing, and imaging investigations. It is recommended to not rely on a single diagnostic test or clinical or laboratory finding, as none has sufficient diagnostic power to establish or exclude the diagnosis of ACC. The best combination of diagnostic investigations is not known.
The preferred initial imaging technique is abdominal ultrasonography (US). It is cost-effective, noninvasive, widely available, and accurate.
Other suggested imaging studies in select patients may include hepatobiliary iminodiacetic acid scanning, which has the highest sensitivity and specificity for ACC diagnosis compared with other imaging modalities. The accuracy of MRI is comparable to abdominal US. The accuracy of CT scanning for the diagnosis of ACC is considered poor.
Surgical Treatment
The recommended first-line treatment for ACC is laparoscopic cholecystectomy.
Laparoscopic cholecystectomy should be avoided in patients with septic shock or absolute anesthesiology contraindications.
Laparoscopic cholecystectomy is suggested to be safe and feasible in patients who have Child-Pugh A or B cirrhosis, those of advanced age (>80 years), or women who are pregnant.
If there is difficulty with anatomic identification of structures during cholecystectomy, the recommended procedure is laparoscopic or open subtotal cholecystectomy.
Conversion from laparoscopic to open cholecystectomy is recommended in patients with severe local inflammation, adhesions, bleeding from the cystohepatic (Calot) triangle, or suspected injury to the bile duct.
Timing of Cholecystectomy in ACC
If adequate surgical expertise is available, the recommended timing for early laparoscopic cholecystectomy is that it should be performed as soon as possible, within 7 days from admission to the hospital and within 10 days from symptom onset.
If early laparoscopic cholecystectomy cannot be performed in the recommended time parameters, delayed laparoscopic cholecystectomy should be performed after 6 weeks from first clinical presentation.
Alternative Treatments & Gall Bladder Drainage in Patients Not Suitable for Surgery
For patients who refuse surgery or those who are not suitable to undergo surgery, nonoperative management with best medical therapy (ie, antibiotics, observation) is suggested.
Alternative treatment options can be considered in patients in whom nonoperative management fails, those who still refuse surgery, and those who are not suitable for surgery.
Gallbladder drainage is recommended in patients with ACC who are not suitable for surgery; this procedure converts a septic patient with ACC into a nonseptic patient.
Delayed laparoscopic cholecystectomy can be offered to patients after perioperative risk is reduced; this decreases the re-admission rate for ACC relapse or gallstone-related disease.
In patients with ACC who are not suitable for surgery, alternatives to percutaneous transhepatic gallbladder drainage include endoscopic transpapillary gallbladder drainage or US-guided transmural gallbladder drainage; both are considered safe and effective alternatives if performed at a high-volume center by a skilled endoscopist.
In this select group of patients, endoscopic transmural US-guided gallbladder drainage with lumen-apposing self-expandable metal stents is preferred over endoscopic transpapillary gallbladder drainage.
Antibiotics in ACC
The routine use of postoperative antibiotics is not recommended in uncomplicated ACC when the focus of infection is controlled by cholecystectomy.
In complicated ACC, it is recommended that an antimicrobial regimen is prescribed; it should be based on the presumed pathogens involved and major resistance patterns.
In the case of complicated ACC with a high risk for antimicrobial resistance, it is recommended that the antibiotic regimen be targeted based on the results of a microbiological analysis, which ensures adequate antimicrobial coverage.
For more information, see Laparoscopic Cholecystectomy and Acute Cholecystitis Imaging.
For more Clinical Practice Guidelines, go to Guidelines.
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Pediatric Cholecystitis. Diagram illustrating the technique for laparoscopic cholecystectomy. The gallbladder is retracted with grasping 5-mm laparoscopic instruments, and clips are applied over the cystic duct and artery.
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Pediatric Cholecystitis. Photograph of a gallbladder filled with numerous small cholesterol stones.
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Pediatric Cholecystitis. Operative photograph illustrating the position of small (5 mm, 10 mm) trocars in the abdomen of a 12-year-old child undergoing laparoscopic cholecystectomy. By using this technique, the surgeon can avoid large incisions and remove the gallbladder safely.
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Pediatric Cholecystitis. Photograph illustrating the role of endoscopic retrieval of common bile duct stones. The picture shows a balloon placed via the endoscope into the ampulla for extraction of a cholesterol stone that was occluding the common bile duct.
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